Provider Demographics
NPI:1003576364
Name:BONAR, MALLORY OLIVIA
Entity Type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:OLIVIA
Last Name:BONAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28407 STATE ROUTE 7
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-5152
Mailing Address - Country:US
Mailing Address - Phone:740-371-5476
Mailing Address - Fax:
Practice Address - Street 1:28407 STATE ROUTE 7
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-5152
Practice Address - Country:US
Practice Address - Phone:740-371-5476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-28
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
005929101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)